IN THE UNITED STATES BANKRUPTCY COURT FOR THE WESTERN DISTRICT OF PENNSYLVANIA In Re: Debtor : : : : : : : : : : : Bankruptcy No. Chapter 13 Movant v. Related to Document No. Respondent(s) DOMESTIC SUPPORT OBLIGATION CLAIM HOLDER REPORT Debtor Daytime Phone:_________________________ Evening: ____________________________________ Attorney Name:________________________________________________________________________ Name of Claim Holder:__________________________________________________________________ Address of Claim Holder: _____________________________________________________________________________________ Mailing Address City/State ZIP Code Support Type: Spousal Support _______________________ Both _________________________________ Child Support ________________________________ The following information must be completed for each support obligation: Name of Applicable State Agency Where Claim Holder Resides: ______________________________________________________________________________ Payment Address: ______________________________________________________________________________ ______________________________________________________________________________ Mailing Address City/State ZIP Code Account #: ____________________________ Monthly Payment Amount: $_____________ Date Payment Late: _____________________ Agency Phone #: _____________________________ Monthly Due Date: ___________________________ Years Remaining: ____________________________ Are ongoing payments being made to the claim holder by Wage Orders? Yes______ No______ Is the Debtor currently employed? Yes______ No______ If yes, Employer Information: ______________________________________________________________________________ Mailing Address City/State ZIP Code PAWB Local Form 22 (07/13) American LegalNet, Inc. www.FormsWorkFlow.com